My grampa is tall as trees ....

“I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
~Maya Angelou

My mother is a writer/poet. She wrote a wonderful children's short story that, I think, is fantastic and describes from a child's point of view how she looks up to her grandfather. Eventually, her grandfather dies and how she has difficulty believing that can happen because "My grampa is tall as trees." I feel this story emulates some of what may be occurring today in the academic world. See academics has always been seen as an area that is kind of sacred. It was the place that all of the "bad cases" were sent to. It was the place were the undeserved and uninsured could get care when the private physicians refused to see them. It was the place where you, as a physician, were told, "yes you may get payed less, but you will not have to work as hard as the private guys; you will have protected time to do 'academic endeavors'; and you will be respected for the 'specialty care' you provide." Times have changed.

"My grampa is tall as trees. Tough as tigers. Big as bears. When he walks the house rumbles and the china in Gramma's china closet shakes. I love mama more than peanut butter. But grampa is tall as trees"

In the past, orthopaedic surgeons at academic centers were protected from the world of billing. There was not as much of a concern for the costs of medical care. The expectation was as an academician, you were perfecting your craft. Part of your job was to search for advances in medical care. The clinical side was where you would practice your theory. You were told, "publish or perish." It was important that you taught others, spoke at meetings, get your and the institution's name out there. By speaking and teaching in and outside of your institution, you will gain prestige.

"Grampa's eyebrows are as big as clouds, and his wink is quick as lightning. Only I am fast enough to catch it. he always winks when mama makes a fuss. She tries to make him wear the new sweaters she buys him. The ones wihout the holes. Or make me wear dresses and comb my hair. I love mama more than biscuits and eggs with the juice runnin' out. But grampa is tall as trees."

The greats come from very academic institutions. They published papers and operated with residents. The did invited lectureships and taught new procedures. They were seen at the forefront of medicine. Academics is were the new ideas were born, practiced, and then released to the mainstream. Academicians became set in their ways. Doing things they way they have always done them without regards to cost. The clinical work both clinic and OR could be performed by residents. Trauma cases would be unsupervised while they continued to perfect their craft, either by writing or researching.

"In the mornin' I can smell cinnamon and coffee. The coffee is my mama. Grampa smells like cinnamon. I jump downstairs and try to rattle Gramma's china in the china closet, race through the room where no children are allowed, run into the kitchen and hop on Grampa's knee. Without a word. And I sit and watch him read the big black book. I know he's talkin' to God.

At many academy events, many academic physicians would present their research and speak in forums. There began to be a little shift with industry and some large group practices doing independent research away from the academic meccas.

The government reevaluated it's billion dollar insurance company (medicare) and realized that they should not pay twice for treatment of patients. "See we (government) pay residents already. So if only residents only perform the case, we will not pay and we will consider billing on those occasions fraud." This crack down place the academic and county institution under the spot light. It requires many people to adjust. They was more time to be spent directing are of patients and procedures and less time dedicated to research. "This was not that much of a problem I'll just do less research." For some, this was hard, but eventually they adjusted.

"Sometimes we take long walks and talk to trees and try not to step on cracks. Grampa tells me stories about the army ants that ate up a whole village of people. Just mowed down everything in sight. Millions of 'em. we sit under trees and wonder what they would say if they could talk."

In the position as educator, this physician had to educate both medical students, residents, and other physicians. This was part of their job. Many were baby boomers and had been trained under an iron fist and wielded their fist in the same manor. As political correctness came into fashion, out went much of the tolerance for the thrower and screamer. Write ups and visits to anger management discussing your feelings with your mother became more common. Resident physicians began to ask for the education. They want a handout with the lecture and they may ask why like a 2 year old child. Accepting what you say as gospel have gone to the way side. Learners actually want to learn from you and not just be a grunt. "Why can't they just do the work? It doesn't have to make sense, just believe what I tell you. Would I lie to you?"

"Grampa has two suits. One for Sunday. The other he never wears. he says he's savin' it for when he goes up in heaven to see Gramma a and have an important meeting with god. In the meantime he wears baggy overalls with lumpy pockets full of gum, his tobacco pouch, and a gold watch with a broken chain. She fusses about my overalls which are brighter and stiffer than grampa's and tries to put ribbons in my hair. I love Mama better than the honey apple raisin cakes from th bakery, but Grampa is tall as tress."

As times began to change, the pushes on the academic physician became worse. Cuts in insurance payments on basic procedures began to be noticed. The hospitals and practices began to reevaluate where money was being generated and were it was being lost. There began to be an encouragement to increase revenue by increase clinical flow. This again infringed on research time. At the same time that clinical practices were increasing, the amount of extended care providers and residents were not. The appeal for the academic practice began to decline. The politics within the university also was stifling. Creating more hassle than help.

"One night there was a big storm and the lights went out. It thundered and lightning and something bigger than Grampa shook the earth. Grampa said God was bigger than thunder and lightening and some people thought that when it stormed, God was angry. But Grampa said it was just his way of remind us that he is still here. Grampa says that God is old as dust, quicker than lightning, bigger than bears, and better than a bushel of honey apple raisin cakes WARMED WITH BUTTER."

In the private sector, things began to become more enticing. Specialty hospitals, surgery centers, and MRI scanners became a great money generator for the private physician. This made the financial difference greater and the attraction of younger physicians to the more profitable and less hassle private practice more appealing.

The government began to investigate the academic institutions for fraud. The restrictions for medicare and medicaid billing became increasingly tough. The possibility of a malpractice suit made the education of young minds more difficult. It require more supervision cause by the risk of malpractice and the restrictions governmental restrictions on billing. The physician who's life was once protected form many of the private worried by the academic system was now becoming more like a private practitioner without the financial rewards.

Learners, the residents, began to protest the previous work hours and ask for less hours. The ACGME placed restrictions on the resident work hour in response to the press and resident physician complaints. Educators where required to teach more and become more efficient at educating in less hours; as well as, increase the clinical revenue and produce publishable research. Why would anyone choose this as a life? There seems to be no benefit.

"Then on day I woke up and didn't smell the cinnamon or the coffee. I ran downstairs and didn't even try to rattle Grandma's china in the china closet, race through the room where no children are allowed, and went into the kitchen to jump on Grampa's knee.

But Grampa wasn't there

In his chair sat my Mama holding the big black book and looking at me with tears in her eyes. She told me that Grampa was ready to put on his suit and go up to heaven with Gramma to meet God. She said we could see him one more time in a church with all his family and friends. She said he would be in Godsleep and be Godstill. That means that his eyes would be closed for a long time and that he would be still and stiller than I can sit on Grampa's knee after he says 'In a minute.'"

As the practice of working in a university setting become more restrictive, it will have to adapt. It is extremely important that the educational structure begin to change to accommodate the changes in the system. We have to balance the differences between academic and private practice. The work load has become equivalent. The benefits of having residents are decreasing and sometime can be somewhat burdensome. The prestige of a academic physician that may have once been there is gone and can easily be overcome by the financial gains in a private setting. With many of the restrictions that have been imposed, it may become more difficult to replenish the numbers of academicians who are retiring.

"Now I can ride my tricycle past the prickly bush, all the way to Mr. Hammond's house and watch him cut the hedges. Mama's going to get me a bicycle with training wheels. And they finally came to carry away the old Dogwood tree that fell in the storm.

Now I talk to God even when there is no thunder to remind me. I say, 'Thank you, God for Mama, and Grampa and Gramma, who are with you, and my new friend, Mr. Hammond. and my brand new bicycle with the training wheels. Amen.'

And if I'm Still - almost Godstill - stiller than when I sat on Grampa's knee after he said 'In a minute, Sister' I can hear grampa smile and say.

'Good mornin' sister."

In the end, I think things will begin to balance out. As long as there are people willing to inspire, there will be people willing to be inspired. With that inspiration, maybe they to will wish to become an educator. Despite all of the restrictions with in the academic practice, the reward of helping others learn the craft may win over.

“Courage is the discovery that you may not win, and trying when you know you can lose.”

~Tom Krause